Chapter 1
Introduction
Inquiry terms of reference
1.1
On 13 September 2012, the Senate referred the following terms of
reference to the Regional and Rural Affairs and Transport References Committee
for inquiry and report by 29 November 2012:
(a)
the findings of the Australian Transport Safety Bureau into the ditching
of VH-NGA Westwind II, operated by Pel-Air Aviation Pty Ltd, in the ocean near
Norfolk Island airport on 18 November 2009;
(b) the nature of, and protocols involved in, communications between
agencies and directly interested parties in an aviation accident investigation
and the reporting process;
(c)
the mechanisms in place to ensure recommendations from aviation accident
investigations are implemented in a timely manner; and
(d) any related matters.
Conduct of the inquiry
1.2
Notice of the inquiry was posted on the committee's website. The
committee also advertised the inquiry in The Australian and wrote to key
stakeholder groups, organisations and individuals to invite submissions.
1.3
The committee received 22 public submissions as well as supplementary
submissions which are listed at Appendix 1. The committee also received several
in camera submissions.
1.4
The committee received a large volume of material from the Australian
Transport Safety Bureau (ATSB) and the Civil Aviation Safety Authority (CASA),
as well as a number of late submissions. The reporting date for this inquiry
was extended several times to enable the committee to further consider the
written evidence received and to hold a number of additional hearings.
1.5
The committee held public hearings in Canberra on 22 October,
19 November and 21 November 2012, as well as 15 and 28 February 2013. The
committee also held several in camera hearings. A list of witnesses
who gave evidence at the public hearings is available at Appendix 2. A Hansard
record of the committee's public hearings is available on the committee's
website at www.aph.gov.au.
Order for the production of documents
1.6
The committee decided that there was a need to access relevant
information from the ATSB and CASA to be able to judge for itself the internal
processes undertaken by each agency and the inter-agency dealings. Many
thousands of internal ATSB and CASA documents were received through an order
for the production of documents.[1]
This material was received confidentially and the committee takes the
protection of such material very seriously.
1.7
Before deciding whether to publish any of the documentation, the
committee discussed the ramifications at length. In doing so it weighed up the
request for confidentiality against the public interest of the aviation
industry and the travelling public having confidence in the key agencies responsible
for civil aviation safety in Australia. Wherever possible, the committee sought
the views of the ATSB or CASA prior to publication. The committee also
considered that it needed to be able to support its analysis and conclusions as
the internal documents appeared at odds with the evidence given publicly. The
committee also wanted to provide the agencies with the opportunity to explain
key documents in public. For these reasons the committee took the decision in
the public interest to publish a small number of documents but did so with
care, selecting only those documents needed to support its conclusions.
1.8
Of the thousands of documents received from the ATSB and CASA, the
committee published 12. At the conclusion of this inquiry, the committee
decided to return all unpublished documents to their respective agencies.
Acknowledgements
1.9
The committee thanks those organisations and individuals who made
submissions and gave evidence at the public hearings.
1.10
The committee recognises the ATSB and CASA for their cooperation with
the committee's order for the production of documents.
1.11
The committee in particular acknowledges the contributions of the VH-NGA
flight crew and passengers, and thanks them for their time and effort. Their
ordeal was traumatic, and rebuilding their lives has not been easy. The
committee wishes to single out the nurse who kept the patient afloat until they
were rescued, despite difficulties with her own lifejacket, which has
unfortunately resulted in a painful and permanent disability. The committee
hopes to see her receive the assistance she needs and deserves as soon as
possible.
1.12
The committee extends its appreciation to the Department of Defence for
facilitating the two-week secondment of an officer with extensive aviation
accident investigation experience. The committee thanks the officer, the department
and the minister for making the officer available. The committee emphasises
that the secondment served purely to assist the committee in understanding
issues which required technical expertise.
1.13
Finally, the committee is always grateful for the hard work and
diligence of the secretariat. In this inquiry, the enormous volume of material
and its highly technical nature put additional demands on the secretariat, who rose
to the challenge in an exemplary fashion.
Scope and structure of this report
1.14
The report is comprised of 10 chapters as follows:
Chapter 2 Background
Chapter 3 The
ATSB investigation and methodology
Chapter 4 The
ATSB's accident investigation processes
Chapter 5 System
failures
Chapter 6 Regulatory
issues
Chapter 7 Communication
between CASA and ATSB
Chapter 8 Human
Factors
Chapter 9 Key issues around
recommendations and ensuring action
Chapter 10 Proposed
changes to mandatory and confidential reporting
1.15
The committee notes that additional comments or reports in relation to
this inquiry may be tabled in the Senate at a future time.
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